Use of Appropriate Initial Treatment Among Adolescents and Young Adults With Cancer

The past several decades have witnessed improvements in early detection and treatment of cancer, leading to overall improvements in survival from cancer for the US population as a whole. However, relative to young children and older adults, there has been far less improvement in cancer-specific survival among the adolescent and young adult (AYA) patients aged 15 to 39 years during this time (1–4). For example, adolescents aged 15–19 years diagnosed with cancer have experienced only half of the improvement in five-year survival from 1975 to 1998 compared with younger children and adults older than 45 years of age (5). Seeking explanations for the lack of improvement in survival, an expert panel noted that the proportion of AYA cancer patients who receive evidence-based, current and sometimes appropriate “cutting edge” initial cancer treatments in general community practice remains largely unknown and understudied (6,7). One possible barrier to receipt of appropriate initial treatment is that oncologists in community practice who primarily treat older adult cancer patients may not be as familiar with specialized treatment protocols used to treat AYA patients who have tumors biologically different from older adults (8–11). Given these barriers, it is possible that AYAs with cancer treated in community settings may be less likely to receive appropriate treatment than if they had been referred to pediatric specialists or to academic institutions or comprehensive cancer centers where access to state-of-the-art care and clinical trial participation are likely greater (10,12,13). Another potential barrier to receipt of adequate treatment may be socioeconomic status (SES) and insurance coverage. Until recently, AYA patients have been among the highest uninsured group in the US (14). This may be changing with the implementation of dependent coverage to age 26 years under the Affordable Care Act of 2011. However, unemployment after age 25 years may limit the ability of some AYAs diagnosed with cancer to obtain adequate coverage. Socioeconomic status (SES) has been reported to account for racial-ethnic survival disparities in non-Hodgkin’s lymphoma (NHL) survivors independent of other demographic and treatment-related variables, suggesting that for one of the most common AYA cancer types nonclinical factors may be associated with underuse of appropriate treatments. In this study we evaluated the associations of health care setting, physician specialty, patient race/ethnicity or patient SES with receipt of appropriate initial treatment in AYAs with cancer. Our investigation is important because it is among the first to address these topics in a large, population-based cohort treated in a variety of academic and nonacademic settings.